LRTI in children

Question 1

what is the lower resp tract

Answer 1

airway distal to the larynx

Question 2

what are LRTI

Answer 2

tracheitis
pneumonia
bronchitis
empyema
bronchiolitis

Question 3

common infective agents

Answer 3

BACTERIA:

• strep pneumoniae
• haemophilus influenzae
• moraxella catarrhalis
• mycoplasma pnuemoniae
• chlamydia pnuemoniae

VIRAL:

• RSV
• parainfluenza III
• influenza A and B
• adenovirus

Question 4

how common are LRTI

Answer 4

17% of all hospital admissions

bronchiolitis - 9%

LRTI - 7%

Question 5

how common is tracheitis

Answer 5

uncommon

Question 6

features of tracheitis

Answer 6

croup which doesn’t get better

fever, unwell child

Question 7

what is the infectious agent in tracheitis

Answer 7

staph/strep invasive infection

Question 8

what happens to the trachea in tracheitis

Answer 8

swollen tracheal wall

narrowed tracheal lumen

luminal debris

Question 9

management of tracheitis

Answer 9

augmentin

Question 10

how common is bronchitis

Answer 10

very common ++++

Question 11

what is bronchitis and what are the features

Answer 11

endobronchial infection

• loose rattly cough w/ URTI
• post-tussive vomit - violent coughing paroxysms are often followed by emesis
• chest free of wheeze/creps

Question 12

infectious organism in bronchitis

Answer 12

haemophilus

pneumococcus

Question 13

natural hx of bronchitis

Answer 13

following URTI

lasts 4wks

cycles of resolving and recurring: resp virus, clearance stops for <4wks, cough and rattle, clearance almost recovered, resp virus again (common in winter)

mostly self-limiting

60-80% respond to abx

severity decreases each year

Question 14

mechanism of bacterial bronchitis

Answer 14

disturbed mucociliary clearance

• minor airway malacia
• RSV/adenovirus

bacterial infection/overgrowth is 2y

Question 15

normal duration of cough

Answer 15

~50% for 10 days

~20% >2wks

Question 16

management of bacterial bronchitis

Answer 16

make diagnosis

reassure parents

don’t treat - minimal impact on QOL > abx side effects

Question 17

what is bronchiolitis

Answer 17

LRTI of infants

infection of the smaller airways

Question 18

how common is bronchiolitis

Answer 18

30-40% of all infants

commonest cause of LRTI in infancy

peak around 3mths but up to 12mths

Question 19

infectious organisms in bronchiolitis

Answer 19

RSV

paraflu III

HMPV

Question 20

features of bronchiolitis

Answer 20

nasal stuffiness

tachypnoea

poor feeding

crackles +/- wheeze

Question 21

duration of bronchiolitis

Answer 21

when medical attention is sought infant is usually already stabilising

recovery around day 14

50% have symptoms for 12 days

some go on for >16 days

Question 22

management of bronchiolitis

Answer 22

maximal observation

minimal intervention

no indication for: salbutamol, ipratropium bromide, adrenaline, steroids, abx, nebulised hypertonic saline

Question 23

investigations for bronchiolitis

Answer 23

NPA

oxygen sats

no routine need for:

• CXR
• bloods
• bacterial cultures

Question 24

what characterises LRTI

Answer 24

48hrs

fever (>38.5)

SOB, cough, grunting

wheeze makes bacterial cause unlikely

reduced or bronchial breath sounds

infective agents - virus + commensal bacteria

Question 25

pneumonia vs LRTI

Answer 25

pneumonia if:

• focal signs
• crepitations
• high fever

otherwise call it LRTI

Question 26

investigations for community acquired pneumonia (CAP)

Answer 26

CXR and inflammatory markers aren’t routine

Question 27

management of CAP

Answer 27

nothing if symptoms are mild

• review if things get worse

1. oral amoxycillin
   
   1. oral macrolide e.g. erythromycin if penicillin allergy

• only IV if vomiting

Question 28

abx - oral vs IV

Answer 28

when to oral abx:

• when indicated
• non-severe LRTI
• no vomiting
• oral abx win majority of the time (shorter hospital stay and cheaper) BUT fever lasts longer

Question 29

LRTI vs bronchiolitis

Answer 29

LRTI:

• all ages
• more rapid Sx onset
• fever

BRONCHIOLITIS:

• <12mths
• 3 days before reach peak illness
  
  • fever rarely >38C

Question 30

abx for URTI and LRTI

Answer 30

bronchiolitis - not indicated

croup - not indicated

acute LRTI - often not indicated

OM - usually not indicated (consider if <2y/o and bilateral infection)

pharyngitis/tonsillitis - usually not indicated

Question 31

causative organism in whooping cough

Answer 31

Bordetella pertussis

Question 32

how common is pertussis

how can we reduce risk and severity

Answer 32

common (⅓ of children with a cough >14 days have it)

vaccination reduces risk and severity

Question 33

features of pertussis

Answer 33

coughing fits

vomiting and colour change

Question 34

what is empyaema

Answer 34

collection of pus in the cavity between the lung and the membrane that surrounds it (pleural space).

Question 35

what is empyaema a complication of

Answer 35

pneumonia

extension of infection into pleural space

Question 36

features of empyaema

Answer 36

chest pain and very unwell

Question 37

treatment of empyema and prognosis

Answer 37

abx +/- drainage

good prognosis - in contrast w/ adults

Question 38

overall treatment plans for LRTI

Answer 38

1. oxygenation, hydration, nutrition
2. consider abx if indicated

• tracheitis: augmentin
• bronchitis: not indicated
• LRTI/pneumonia: if 2 days fever, cough, focal signs - oral amoxycillin
• bronchiolitis: not indicated
• empyema: IV amoxycillin